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Lt.Col. Saran Jiranansiri, MD Refractive Surgery Lt.Col. Saran Jiranansiri, MD. Cornea & Refractive Surgery, Fort Suranaree Hospital I have no financial interests or relationships to disclose. Overview of Refractive Surgery • Basic anatomy of eye and refractive errors • Correction of refractive errors • Options in refractive surgery • Keratorefractive surgery • Lenticular refractive surgery • Candidate for refractive surgery & Procedure • Refractive surgery Pros & Cons • Adverse events of refractive surgery • Update in treatment of dry eye Basic Anatomy of the Eye http://www.vision-and-eye-health.com Basic Anatomy of the Eye 20 D 40 D 60 D https://clarkscience8.weebly.com Refractive Errors Normal vision Myopia Astigmatism Hyperopia https://theeyeclinicsurgicenter.com Refractive Errors Presbyopia https://i2ioptic.mu/ Correction of Refractive Errors Eyeglasses Contact Lenses https://www.news-medical.net/ Correction of Refractive Errors Eyeglasses Contact Lenses https://www.news-medical.net/ Correction of Refractive Errors Eyeglasses Contact Lenses https://theeyeclinicsurgicenter.com Correction of Refractive Errors https://www.presbyopialife.com/ Correction of Refractive Errors Reading Eyeglasses https://www.presbyopialife.com/ Correction of Refractive Errors https://www.sunglass365.com Correction of Refractive Errors https://www.eyeweargenius.com/ Refractive Surgery Lens Cornea Goal American Academy of Ophthalmology, Basic and Clinical Science Course, Section 13: Refractive Surgery 2018-19 History of Refractive Surgery Wavefront - guided Automated Laser ablations Lamellar Radial Keratotomy Keratoplasty (ALK) Femtosecond laser (RK) SMILE (Intralase) LASIK 1949 1968 1978 1988 1998 2008 2011 PRK FLEX Myopic Keratomileusis Discovery of ablative LASEK (MKH) photodecomposition with excimer laser Epi - LASIK Eng K. Ang, Outcomes of laser refractive surgery for myopia, J Cataract Refract Surg 2009; 35:921–933 Keratorefractive Surgery Incisional RK, AK, LRI, Hex K, Ruiz procedure Surface ablasion PRK, LASEK, Epi-LASIK Excimer MK-LASIK, Femto-LASIK, ReLEx, Lamellar FLEx, SMILE Epikeratophakia, Epikeratoplasty, Myopic Nonlaser lamellar keratomileusis, ICRS Cornea Collagen shrinkage LTK, CK Collagen CCL, CXL crosslinking AAO, BCSC: Refractive Surgery 2020-21 Lenticular Refractive Surgery Anterior chamber PIOL Phakic Iris-fixated PIOL Posterior chamber PIOL MF, Accommodative, Pseudophakic Refractive lens exchange (RLE) Toric IOL Intraocular AAO, BCSC: Refractive Surgery 2020-21 Lenticular Refractive Surgery AC-PIOL Anterior chamber PIOL IrisPC-fixatedRLE-PIOL PIOL Phakic Iris-fixated PIOL MF/Toric IOL Posterior chamber PIOL MF, Accommodative, Pseudophakic Refractive lens exchange (RLE) Toric IOL Intraocular AAO, BCSC: Refractive Surgery 2020-21 Keratorefractive Surgery Keratorefractive Surgery (Available) Surface Flap Lenticule Extraction Abrasion Procedure (ReLEx) PRK LASIK SMILE MK-LASIK Femto-LASIK AAO, BCSC: Refractive Surgery 2020-21 Keratorefractive Surgery Excimer Laser Femtosecond Laser https://www.zeiss.com/meditec/int/specialties/laser-vision-correction/ Candidates for Refractive Surgery • Age > 21 (Stable refraction <0.5D/year) • Myopia, Hyperopia, Astigmatism • PRK +6 to -13D, Astigmatism 0-4D • LASIK +6 to -14D, Astigmatism 0-5D (6D in Hyperopia) • Residual stromal bed thickness, PTA Flap/cap thickness Abrasion depth RSB thickness AAO, BCSC: Refractive Surgery 2020-21 Candidates for Refractive Surgery • No other uncontrolled ocular diseases • Keratoconus • Infection • Dry eye • Blepharitis • Glaucoma • Retinal diseases • Relative contraindication in systemic conditions • DM, Pregnancy/lactation, Medications, Autoimmune disease • Realistic expectation AAO, BCSC: Refractive Surgery 2020-21 Photorefractive Keratectomy (PRK) 50 um • Alcohol • Mechanical ▪ Blush ▪ Blade • Excimer laser https://www.aao.org/eye-health/treatments/photorefractive-keratectomy-prk Photorefractive Keratectomy (PRK) • Thin cornea • Low to moderate correction • Dry eye syndrome • Pain and irritation • Unusual topography • Slow wound healing (3-7d) • Keratoconus suspect • Slow visual rehabilitation • PTK for superficial corneal • Corneal haze/scar/keloid dystrophies, scar • Touch up surgery • Post corneal transplantation • Risk of trauma https://www.aao.org/eye-health/treatments/photorefractive-keratectomy-prk Laser in-situ Keratomileusis (LASIK) Microkeratome LASIK Femto LASIK https://www.aao.org/eye-health/treatments/lasik Laser in-situ Keratomileusis (LASIK) • • Moderate to high correction Flap complications ▪ Free cap, flap wrinkle, • Need for rapid visual button hole flap rehabilitation • Interface complications • Less post-op pain ▪ Epithelial ingrowth, DLK • Dry eye syndrome, ectasia https://www.aao.org/eye-health/treatments/lasik Small Incision Lenticule Extraction (SMILE) Femtosecond laser to create corneal lenticule Lenticule removal https://eyewiki.aao.org/Small_Incision_Lenticule_Extraction_(SMILE) Small Incision Lenticule Extraction (SMILE) • Fast procedure (1 step), 30s. • Not for hyperopia • Moderate to high correction • Touch up surgery by circle • Need for rapid visual enhancement or PRK rehabilitation • Suction loss, retained lenticule • Less post-op pain • Interface complications, ectasia • Less dry eye • Risk for trauma • Presbyond laser blended vision https://eyewiki.aao.org/Small_Incision_Lenticule_Extraction_(SMILE) Dry Eye Disease https://www.eyedocs.co.uk/ophthalmology-articles/oculoplastics/509-lacrimal-syringing Dry Eye Disease 1) Aqueous tear deficiency dry eye • Main+Accessory gland Globlet cell in conjunctiva 2) Evaporative dry eye Craig JP et al, TFOS DEWS II Report Executive Summary, Ocul Surf. 2017 Oct;15(4):802-812. doi: 10.1016/j.jtos.2017.08.003. Epub 2017 Aug 8. Dry Eye Disease 3) Decreased wettability dry eye Tear film instability Kazuo Tsubota, Eye Contact Lens. 2020 Jan;46 Suppl 1(1):S2-S13. Dry Eye Treatment Tear film-oriented therapy based on dry eye disease classification Asia Dry Eye Society (2020) Kazuo Tsubota, Eye Contact Lens. 2020 Jan;46 Suppl 1(1):S2-S13. Dry Eye Treatment Tear film-oriented therapy based on dry eye disease classification Asia Dry Eye Society (2020) May have little to no Step 1 benefit relative to placebo 1. Patient education 2. Local and dietary modification 3. Stop offending medication 4. Ocular lubricants (Preservative) 5. Lid hygiene and warm compresses Craig JP et al, TFOS DEWS II Report Executive Summary, Ocul Surf. 2017 Oct;15(4):802-812. doi: 10.1016/j.jtos.2017.08.003. Epub 2017 Aug 8. Dry Eye Treatment Tear film-oriented therapy based on dry eye disease classification Asia Dry Eye Society (2020) Step 2 1. Nonpreservative artificial tears 2. Eye gel or ointments 3. Punctal occlusion/Moisture chamber 4. Antibiotics, steroid, secretagogues 5. Oral macrolide/Doxycycline Craig JP et al, TFOS DEWS II Report Executive Summary, Ocul Surf. 2017 Oct;15(4):802-812. doi: 10.1016/j.jtos.2017.08.003. Epub 2017 Aug 8. Dry Eye Treatment Tear film-oriented therapy based on dry eye disease classification Asia Dry Eye Society (2020) Step 2 1. Nonpreservative artificial tears 2. Eye gel or ointments 3. Punctal occlusion/Moisture chamber 4. Antibiotics, steroid, secretagogues 5. Oral macrolide/Doxycycline Craig JP et al, TFOS DEWS II Report Executive Summary, Ocul Surf. 2017 Oct;15(4):802-812. doi: 10.1016/j.jtos.2017.08.003. Epub 2017 Aug 8. Dry Eye Treatment Tear film-oriented therapy based on dry eye disease classification Asia Dry Eye Society (2020) Step 2 P2Y2 receptor agonist 1. Nonpreservative artificial tears 2. Eye gel or ointments 3. Punctal occlusion/Moisture chamber 4. Antibiotics, steroid, secretagogues 5. Oral macrolide/Doxycycline Craig JP et al, TFOS DEWS II Report Executive Summary, Ocul Surf. 2017 Oct;15(4):802-812. doi: 10.1016/j.jtos.2017.08.003. Epub 2017 Aug 8. Dry Eye Treatment Tear film-oriented therapy based on dry eye disease classification Asia Dry Eye Society (2020) Step 3 1. Oral secretagogues Pilocarpine (Salagen®) Cevimeline (Evoxac®) 2. Autologous serum eyedrop 3. Contact lenses ▪ Soft bandage CL ▪ Rigid scleral CL Craig JP et al, TFOS DEWS II Report Executive Summary, Ocul Surf. 2017 Oct;15(4):802-812. doi: 10.1016/j.jtos.2017.08.003. Epub 2017 Aug 8. Dry Eye Treatment Tear film-oriented therapy based on dry eye disease classification Asia Dry Eye Society (2020) Step 4 1. Amniotic membrane graft 2. Surgical/permanent punctal occlusion 3. Tarsorrhaphy 4. Salivary gland transplantation Craig JP et al, TFOS DEWS II Report Executive Summary, Ocul Surf. 2017 Oct;15(4):802-812. doi: 10.1016/j.jtos.2017.08.003. Epub 2017 Aug 8. Dry Eye following RF Sx LASIK > SMILE > PRK Raman-Deep Singh Sambhi, Dry eye after refractive surgery: a meta-analysis, J Ophthalmol. 2020 Apr;55(2):99-106. Dry Eye following RF Sx Dry eye management strategies in refractive surgery • Identify and treatment of dry eye preoperatively • Education about dry eye symptoms postoperatively • Treat all aggressively with preservative-free artificial tears • Step dry eye treatment as needed Renato Ambrósio Jr, LASIK-associated dry eye and neurotrophic epitheliopathy: pathophysiology and strategies for prevention and treatment, J Refract Surg. 2008 Apr;24(4):396-407. Refractive Surgery Lt.Col. Saran Jiranansiri, MD. Cornea & Refractive Surgery, Fort Suranaree Hospital.
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